Meeting our returning combat veterans in the

classroom

Jonathan R. Sills, Ph.D.VA Palo Alto Health Care System

December 2, 2010Jonathan.Sills@va.gov

Objectives

Expand understanding of diagnostic signs symptoms of Mild Traumatic Brain Injury and Post Traumatic Stress Disorder.

Share some ways that educators can work more effectively with those students who display mixed mTBI/PTSD symptoms

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Traumatic Brain Injury (TBI) is often identified as the signature injury of the

recent conflicts.

DoD Health Affairs Workgroup TBI Definition

A traumatically induced structural injury and/or physiological disruption of brain function as a result of an external force.

(Vanderploeg 2008)

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TBI is an event that result in one or more of the following

1. Any period of loss or decreased level of consciousness

2. Any loss of memory for events immediately before or after the injury

3. Any alteration in mental state at the time of the injury (e.g., confusion, disorientation, slowed thinking)

4. Neurological deficits (e.g., weakness, balance disturbance, praxis, paresis/plegia, change in vision, other sensory alterations, aphasia.) that may or may not be transient

5. Intracranial abnormalities (e.g. contusions, diffuse axonal injury, hemorrhages, aneurysms).

(Vanderploeg 2008)Sills (2010)

Causes of TBI: Civilian and Military

Civilian Populations Motor Vehicle Accidents (MVA) Sports Injuries Falls Gun Shot Wounds

Military Populations Same as Civilian

Explosions/Blast Injuries Pressure wave, shrapnel/debris, coup/contrecoup,

crush

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Disruptions in cognitive functioning often associated

with TBI Impairments in Attention Slowed Information Processing Learning/Memory Impairments Difficulties In Abstract Reasoning Diminished Executive Functioning

(Sequencing, Planning, Initiation and Inhibition of Behaviors)

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Recovery of Cognitive Functions

Cognitive functioning generally improves with natural healing and with cognitive retraining.

Pace of cognitive return is variable based on intensity of injury– Mild, Moderate, Severe.

Returns in attentional deficits usually

occur prior to any returns in Executive Functioning or Delayed Memory.

Mild and Moderate post injury baseline will generally be achieved within 1 to 2 years.

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Uncertainty of outcome during the recovery

process contributes to distress which along with

TBI ,may contribute to functional impairments in Cognitive, Behavioral, or Emotional functioning.

How do helpers (Health Care Providers, Educators, Family

Members) respond to distress?

Attempt to apply their skills to the best of their ability and often use methods that they have confidence in.

Example –Psychologists may conduct Psychological Assessment.

Results in of Multi Axial Diagnoses Initiation of treatment interventions based on

diagnosis

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Three Major Sources of Data

Clinical HistoryMental Status

ExamTest Data

Conclusion/Diagnosis

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What’s in a Mental Status Exam?

Judgment Orientation Insight Memory Affect/Appearance Thought (content &

process)

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Assessment Difficulties

TBI usually results in behavior and emotional changes that can mimic other psychiatric disorders.

Developing a clear diagnostic impression is complicated.

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Behavioral and Emotional changes often associated with

TBI Increased irritability Increased impulsivity Increased apathy More easily agitated Increased aggression Depression Anxiety Socially Inappropriate

(DVA 2003; Vanderploeg 2006)

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Psychological or Organic Etiologies (DVA 2003)

Psychogenic/Psychatric Symptoms

Neurogenic Symptoms

Denial Anosognosia (lack of awareness ofimpairment)

Anger and irritability Frustration, catastrophic reaction.

Depression Lack of initiative, fatigue, impairedLimited Emotional Expression

Compulsive/hypervigilance Preservation, Failure to multitask Dependence on external controls

Emotional lability Lability of emotional expressiveness.

Social withdrawal Lack of initiative.

Limited sense of the future Impaired planning

Thought disorder Aphasia, anomia, or confusion

Personality or conduct disorder Impulsivity, social disinhibition

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Post Concussive Syndrome symptoms compared to PTSD

Post Concussive Syndrome Symptoms Insomnia Impaired memory Poor concentration Depression Anxiety Irritability Headache Dizziness Fatigue Noise/light intolerance

PTSD Symptoms Insomnia Memory problems Poor concentration Depression Anxiety Irritability Stress symptoms Emotional numbing Avoidance

(Vanderploeg 2006)

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Differential Diagnosis between Post-Concussion Syndrome &

PTSD

PTSD symptoms include reexperiencing of the trauma or numbing of general responsiveness, while PCS does not.

PCS is characterized by headaches, dizziness, ringing in ears, generalized memory problems, or subjective intellectual impairment, while PTSD is not.

(Mittenberg and Strauman 2000 from DVA 2003)

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Comorbity in Mild TBI Populations

RAND Corporation Study (2008) Surveyed 1,965 service members

18.5% met criteria for either PTSD or depression

19.5% reported a probable mild TBI 37.4% of those individuals with a history

of mTBI also had either PTSD or depression

(Vanderploeg 2008)

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Complex Comorbid Relationship between PTSD and SUD

PTSD and substance abuse co-occur at a relatively high rate

Estimates of substance use disorders and PTSD Rate among patients in SUD treatment ranges from

12%-59% 58% of veterans in SUD programs have lifetime PTSD 73% of male Vietnam veterans who met diagnostic

criteria for PTSD also qualified for lifetime SUD disorders

(Walser 2008)

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25% of Returnees Report Problematic Drinking After Deployment (Hoge, 2004; Walser 2008)

17%13%

25%

18%

24%21%

35%

29%

00.050.1

0.150.2

0.250.3

0.350.4

Have you used alcohol morethan you meant to?

Have you felt you wanted orneeded to cut down on your

drinking?

Pre-Deployment Army Afghanistan Army Iraq Marine Iraq

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Diagnostic Picture is Complicated

Example-- Axis I: Cognitive Disorder NOS

PTSD Major Depressive Disorder Polysubstance Abuse

Axis II: Deferred R/O Personality Disorder NOS, cluster B

traits Axis III: Reported Multiple TBI, Chronic Pain--Back Axis IV: Disruption in occupational, academic, and

social functioning Axis V: GAF = 52

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What to Do with this Clinical Presentation? (Uomoto 2008)

Blast ExposureTBI

Substance AbuseDisorder

Depression

PTSD

Limitations in Role Functioning And Participation

FinancialStress

Vocational/Academic

Challenges

Marital Stress

Possible Diagnosis Impairment in Function

and Social Reintegration

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Theories of PTSD

Biological Responses to Danger Flight, Fight, or Freeze

Existential– Violation of “What is Right”

Themis– a mark of civilized existence, sometimes it means right custom, proper procedure, social order, or justice.

(Shay 1994 and 2003)

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Tips for working with students

Educate yourself about military culture.

Example -- Active Duty vs. Reserve

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Active Duty vs. Reserve Active duty = currently serving full time in military.

Military reserve force = citizens who combine a military role or career with a civilian career.

Reservists during cold war performed minimum of 39 days of military duty a year.

In support of the Global War on Terror, a large number of Reservists have been performing in operational capacity for an extended period of time.

Reservists tend to be older than active duty service members

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How educators can support learning for this population

Educators Should Slow Down Remember TBI makes the world appear to be moving at

a higher rate of speed than pre injury.

Be More Directive in Office Hours

Manage Expectations for Success

Accommodate for Current Cognitive Functioning. Play to students cognitive strengths

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Ways to Play to Cognitive Strengths

Use Mnemonics Provide Cues and “Chunking” of Information

Use Stories Provides context and aids with recall of information

Use repetition minimize confusion distributed practice effect

Use Visual Aids Provide information across multiple sense

modalities Sills (2010)

Various experiences of working with student’s that display an mTBI/PTSD

symptoms May display a tendency to view things in

all or nothing manner.

May display a tendency to focus on perceived threats.

Negative Intrusive Thoughts and Existential Issues can contribute to communication breakdowns

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Tips for working with students with mTBI/PTSD

Provide control and decision making when possible Paper vs Midterm Group Projects inside vs outside of class

Support cognitive flexibility by asking questions that allow for 3 points of view.

Be mindful of location of seating Be mindful of making ad hoc statements

that add minimal value to learning and can be easily misconstrued.

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“Learning Opportunities”-- Classroom Examples

Clinical Psychology Talking about human behavior, disorders, and

diagnosis without a warning introduction

Applied Cultural Anthropology Environmental scanning and community

mapping activities outside of class

Philosophy and Political Science class Discussions Example -- Platonic dialogue “Laches” (Courage) which

begins with two fathers discussing if their sons should be trained to fight in armor.

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Educators should “Holdfast.” Humble – check your ego. Observe – the student and your feelings. Listen – to what the student is telling you. Dedication – be available. Fair– Don’t expand things out of proportion or

make excuses that end up unnecessarily lowering expectations.

Athentic— Don’t lie, exaggerate, get competitive (male staff in particular) or pretend to be something that you are not.

Stay with principles -- Be clear on your priorities and act accordingly.

Truthworthy – Be consistent. Testing over time=trust.

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In Review Combat veterans are returning from the current

conflicts with a variety of comorbid conditions and challenges.

Educators can support learning in returning combat veteran students by expanding their own knowledge of these conditions, military culture, and by making minimal changes to their established teaching practices.

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Thank You

Questions?

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References

Collins, R. (2006) Polytrauma Rehabilitation: A New Model of Care. Paper presented at the VA Psychology Leadership Conference held in Dallas Texas.

Department of Veterans Affairs (2003) Traumatic Brain Injury: Independent Study Course. Veterans Health Initiative

Kennedy, M (2008) Family Centered Care within Interdisciplinary Polytrauma Rehabilitation, Paper presented at the VA National Polytrauma Conference held in San Diego, California.

Neibuhr, S (2008) Professional Self Care: protecting and sustaining your vitality, effectiveness and resilience?, Paper presented at the VA National Polytrauma Conference held in San Diego, California.

Ruzek,J (2008) Towards PTSD treatment improvement for Veterans, National Center for PTSD Clinical training program

Shay, J. (1994) Achilles in Vietnam: Combat trauma and the undoing of character. New York:

Scribner Book Company Shay, J. (2003). Odysseus in America: Combat Trauma and the Trials of Homecoming.

New York: Scribner Book Company.

Uomoto, J (2008) VA outpatient Care for PTSD and Mild TBI/Polytrauma, Paper presented at the VA

National Polytrauma Conference held in San Diego, California.Vanderploeg, R. (2008) Mild TBI and Mental Health Comprbidities: What do we Know?,

Paper presented at the VA National Polytrauma Conference held in San Diego, California.

Vanderploeg, R. (2006) Traumatic Brain Injury within the VHA and DoD Systems of Health Care, Paper presented at the VA Psychology Leadership Conference held in Dallas Texas.

Wasler, R (2008) Posttraumatic stress disorder and Substance Abuse: Dual Diagnosis overview and Treatment, National Center for PTSD Clinical Training Program

Zeiner, H. (2007) War Stories from Ward 7-D. California Connected. Programming aired on KQED Bay Area Public Access Television Network. For more information see http://www.californiaconnected.org/tv/?s=7-d

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